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Mario C. Raviglione, M.D. Director, Stop TB Department WHO, Geneva, Switzerland Towards universal access: Urgent action to respond to TB and M/XDR-TB 2 nd Meeting of the Global Laboratory Initiative Veyrier-du-Lac, France, 15-16-October 2009 WHO & Fondation Mérieux

Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

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Page 1: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Mario C. Raviglione, M.D. Director, Stop TB Department WHO, Geneva, Switzerland

Towards universal access:

Urgent action to respond to TB and M/XDR-TB

2nd Meeting of the Global Laboratory Initiative Veyrier-du-Lac, France, 15-16-October 2009

WHO & Fondation Mérieux

Page 2: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Aims of this presentation

To review the global burden and state of control of TB,TB/HIV,MDR/XDR-TB

To describe the impediments to progress of control efforts

To make the point about the crucial importance of modern laboratories and rapid testing if we target universal access to care

Page 3: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Estimated number of

cases

Estimated number of

deaths

1.771.77 million million ((2727 per per 100,000100,000))

9.279.27 million million ((139139 per per 100,000100,000))

~150,000 511,000

All forms of TB Greatest number of cases in Asia; greatest rates per capita in Africa

Multidrug-resistant TB (MDR-TB)

Extensively drug-resistant TB (XDR-TB) ~50,000 ~30,000

HIV-associated TB 1.4 million (15%)

456,000

Latest global TB estimates - 2007

Page 4: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

No estimate

0–4

20–49

>= 50

5–19

HIV prevalence in TB cases, (%)

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2009. All rights reserved

HIV prevalence among TB cases, 2007

Global estimate: about 1.4 million TB/HIV cases and 456,000 TB/HIV deaths a year

Page 5: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

MDR-TB % among new cases, 1994-2007

0.00 - 0.99 1.00 - 2.99 3.00 - 5.99 6.00 – 10.00 >10.00 No data

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2009. All rights reserved

* Sub-national coverage in India, China, Russia, Indonesia.

Page 6: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Top 19 settings with MDR among new cases > 6% (1994-2007)

0.0 5.0 10.0 15.0 20.0 25.0

Dominican Republic*

Georgia

Heilongjiang Province, China

Inner Mongolia Autonomous Region, China

Henan Province, China

Orel Oblast, RF

Armenia

Lithuania

Liaoning Province, China

Latvia

Ivanovo Oblast, RF*

Mary El Oblast, RF

Estonia

Kazakhstan*

Tashkent, Uzbekistan

Tomsk Oblast, RF

Donetsk Oblast, Ukraine

Republic of Moldova

Baku City, Azerbaijan

Indicates survey data reported in an earlier phase of the project

Page 7: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Trend of MDR-TB among new cases Estonia, Latvia and…Tomsk, RF

% MDR among new cases

0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

1997 1999 2001 2003 2005

p=0.6213Estonia

0102030405060708090

100

1997 1999 2001 2003 2005 2007

Latvia 0.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

1997 1999 2001 2003 2005

p=0.3260

TB notification rate

0

10

20

30

40

50

60

70

1997 1999 2001 2003 2005 2007

0

20

40

60

80

100

120

1998 2000 2002 2004 20060.00

0.05

0.10

0.15

0.20

0.25

0.30

0.35

1997 1999 2001 2003 2005

p=0.0055Tomsk oblast, RF

Page 8: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.

Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2009. All rights reserved

Countries with at least one confirmed XDR-TB case, as of June 2009

Argentina Burkina Faso Georgia Kenya Nepal Qatar Swaziland Viet NamArmenia Canada Germany Latvia Netherlands Republic of Korea SwedenAustralia China India Lesotho Norway Republic of Moldova ThailandAzerbaijan Colombia Iran (Islamic Republic of) Lithuania Oman Romania UkraineBangladesh Czech Republic Ireland Mexico Peru Russian Federation United Arab EmiratesBelgium Ecuador Israel Mozambique Philippines Slovenia United KingdomBotswana Estonia Italy Myanmar Poland South Africa United States of AmericaBrazil France Japan Namibia Portugal Spain Uzbekistan

Page 9: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Treatment success on target (>85%), case detection stalling after years of expansion

Europe: 70%, Africa: 75%, Americas: 75% Africa: 47%; Europe 51%; East. Med: 60%

Estimated case detection (%) of sputum smear + cases

Target 70%

0

20

40

60

80

1990 1995 2000 2005

Whole Country DOTS

Treatment success (%) among sputum smear+ cases

77 79 77 79 81 80 82 82 82 83 84 85 85.0

0

10

20

30

40

50

60

70

80

90

100

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

63% in 2007

2010

Target 85%

What would better laboratories and rapid testing take us to?

Page 10: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

0

50

100

150

200

250

300

350

1,990 1,995 2,000 2,005 2,010 2,015

0

5

10

15

20

25

30

35

1,990 1,995 2,000 2,005 2,010 2,015

TB prevalence and mortality

Prevalence (cases/100,000) Mortality (deaths/100,000)

On track for both in AMR, EMR and SEAR On track for prevalence in WPR

Will not be reached in AFR and EUR

Target = 148 Target = 14

Page 11: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

-

50

100

150

200

250

1990 1995 2000 2005

TB c

ases

/100

k/yr

SE Asia

World

W Pacific

E Med

America

-

50

100

150

200

250

300

350

400

1990 1995 2000 2005

TB c

ases

/100

k/yr

-

10

20

30

40

50

60Africa

Europe

World

35% TB 65% TB

TB incidence rates stable or falling slowly after epidemic peaks in Africa and Europe

Page 12: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

What are the challenges in 2009?

1. DOTS not of high quality everywhere; only 63% of all estimated cases officially notified; delayed diagnosis

2. TB/HIV, especially in Africa; MDR-TB, especially in former

USSR and China; XDR-TB everywhere and in Africa

3. Weak health systems and services compromising TB care; lack of bold policies on laboratory services, free access to care, drug quality, human resources, infection control, etc.

4. Not all practitioners, non-state and even governmental,

working at high standard; weak links public-private 5. Communities often un-aware, un-involved, not mobilised 6. Research not yet delivering innovative tools, and operational

research often outside of the interest of TB "controllers"

Page 13: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

New challenges require the Stop TB Strategy

The Global Plan 2006-2015 defines direction and costs

The direction today…

2006-2015: $ 60 billion

necessary to control TB in

endemic countries

$ 11 billion

necessary to develop new

tools

Page 14: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

MDR-TB: recent progress

2007: 3600 MDR-TB cases out of 30,000 notified were put on treatment under GLC standards = 1% of the

estimated SS+ MDR-TB cases

In 2009, 14,000 projected

Major delay vs GP

Page 15: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Full implementation of Global Plan: 2015 MDG target reached but TB not eliminated by 2050

Propects for TB elimination by 2050

1

10

100

1000

10000

2000 2010 2020 2030 2040 2050Year

Inci

denc

e/10

0,00

0/yr

Elimination 16%/yrGlobal Plan 6%/yrCurrent trajectory 1%/yr

Elimination target: 1 / million / year by 2050

Projected incidence 100x bigger than elimination target in 2050

Page 16: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Deciding on key general health policies needed to control TB

Page 17: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Bottlenecks to scale-up M/XDR-TB prevention and management

• Major gaps in TB control • Extremely weak M/XDR-TB

management and care • Health workforce crisis • Inadequate laboratories • Quality of anti-TB drugs not

assured • No restriction of anti-TB drug use • Absent infection control • Insufficient research • Major financial gaps

From: The Beijing "Call for Action" on TB Control and Patients Care, April 2009

Page 18: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

62nd World Health Assembly, 2009 Prevention & control of M/XDR-TB

WHA62.15 Member States are urged to: 1. Achieve universal access to diagnosis and treatment of M/XDR-TB

a) Develop a comprehensive framework for management and care of M/XDR-TB, including DOT, community-based and patient-centred care

b) Strengthen health information and surveillance systems c) Aim to ensure removal of financial barriers for equitable access, and protect patient's rights d) Make available sufficiently trained and motivated staff e) Strengthen laboratory systems and accelerate access to faster and quality-assured

diagnostic tests f) Engage all public and private care providers in managing TB and strengthen primary care g) Ensure infection control policies developed and implemented in every care facility h) Ensure un-interrupted supply of first- and second-line medicines which meet WHO PQ or strict

national regulatory authority standards, and that FDC of proven bioavailability are prioritized i) Strengthen mechanisms to ensure that TB medicines are sold on prescription only by accredited

providers j) Undertake effective advocacy, communication and social mobilization k) Establish national targets to accelerate access to treatment

2. Enhance quality and coverage of DOTS in achieving targets to prevent MDR-TB 3. Use all possible financial mechanisms to fulfil commitments and fill funding gaps 4. Increase investments in operational research and R&D for new tools

Page 19: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Control of M/XDR-TB requires more than just TB programmes' efforts Policy changes are fundamental!

• Remove financial barriers (UHC) • Establish a network of labs ensuring

rapid molecular tests are available • Ensure availability of quality drugs • Regulate the use of all anti-TB drugs • Introduce infection control • Promote R&D • Mobilize resources domestically and

internationally

Page 20: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Diagnosing and treating MDR-TB in the un-reachable: the challenge

The "bush" - Swaziland

Favela "Rocinha", Brasil Simply, the poorest…

Page 21: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

4/28/2011

Stop TB Strategy (TBS)

L. Blanc, Coordinator

Care Delivery Innovation M/XDR-TB Response

TB/HIV Response

Advocacy & Strategic Planning Social Mobilisation & Partnering Branding, Marketing & Communication Global Drug Facility (GDF) & Green Light Committee (procurement) TB Research Movement

TB REACH

Stop TB Partnership Secretariat (TBP)

M. Espinal, Executive Secretary

Surveillance & Monitoring

Epidemiology & Impact Assessment

Economics, Budgeting & Financing

TB Operations & Coordination (TBC)

P. Nunn, Coordinator

Global Fund Collaboration

TBTEAM

Regional Collaboration

Green Light Committee Mechanism (GLC)

6 Regional Offices, all with TB teams

WHO Offices,

including TB-specific staff in 45 countries

STB Director's Office (STB/DO) M. Raviglione, Director

D. Weil, Coordinator, Policy & Strategy Policy, Planning, Research Coordination, Resource Mobilization & Communications

28 April 2011

Administration & Finance Operations Team (AFO)

A. Vijay, Department & Partnership Resource Administrator

TB Laboratory Strengthening (TBL)

K. Weyer, Coordinator

TB Monitoring & Evaluation (TME)

K. Floyd, Coordinator

Global Laboratory Initiative (GLI)

Supranational Reference Laboratory Network (SRLN)

EXPAND-TB Project

Page 22: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Need for new Diagnostics at each Level of the system

Page 23: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Potential impact of new diagnostics in SE Asia

Sou

rce:

L. A

bu R

adda

d et

al,

PN

AS

, 200

9

•Led & NAAT at microscopy lab level •Dipstick at point of care

Page 24: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

1. Norms, standards and policies - From research and evidence into policy

• Expert committees, review of evidence inform STAG-TB discussion

• STAG-TB recommends to WHO and policy is made, with guidelines

• Dissemination to Member States, GF, UNITAID, World Bank…

• Operational Research for adaptation and revision of policies

2. Strategies, guidance towards implementation -

From policy to practice • Guidelines for countries • Technical assistance, training for implementation • Support for resource mobilization

WHO's functions in re-tooling Two phases

Page 25: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

WHO's recently endorsed technology in diagnostics

• 2007: Liquid culture media • 2007: Rapid speciation technology • 2008: Line-probe assays

• Future processes:

• 2009: LED microscopy • 2010: Other NAAT?

Page 26: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

1. Winter 2007-08: Evidence from literature and new study in SA 2. March 2008: WHO Expert Committee's review & recommendations 3. June 2008: STAG-TB recommends to WHO to promote LPAs 4. 1st July 2008: WHO announces a new policy recommending use of LPAs

for all countries for rapid MDR-TB diagnosis 5. 1st July 2008: UNITAID announces US$ 26 million support

The example of the Line Probe Assays From Research to Policy and Practice

Officials Praise New Test for Drug-Resistant TB

By LAWRENCE K. ALTMAN

Page 27: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

The way forward in laboratory strengthening – what will WHO do?

1. Support the Global Laboratory Initiative secretariat

2. Promote with ministries the need to strengthen labs

3. Support countries in their search for financing externally (UNITAID, WB, GF, bilaterals etc) or domestically

4. Coordinate with all partners to make GLI a success

5. Pursue endorsement of new technology, related policy making, and transfer of technology

6. Never stop promoting research into new diagnostics and the need for a point-of-care tool

7. Favour integrated technology and broad laboratory network development

Page 28: Towards universal access: Urgent action to respond to TB ... · Ivanovo Oblast, RF* Mary El Oblast, RF Estonia Kazakhstan* Tashkent, Uzbekistan Tomsk Oblast, RF Donetsk Oblast, Ukraine

Many thanks to all

To end this scourge is a mere question of civilization (Jorge Sampaio, UN SE to Stop TB)